A Framework for Automated Continuum of Care Reporting of Selected Notifiable Diseases using Electronic Medical Record Data: Preliminary Data for HIV in Massachusetts Elizabeth C. Dee, 1,2 Noelle Cocoros, 1 Liisa M. Randall, 2 Hannah Rettler, 2 Mark Josephson, 3 Michael Klompas 1,4 1 Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute 2 Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health 3 Massachusetts League of Community Health Centers 4 Department of Medicine, Brigham and Women s Hospital
Objective Describe the Massachusetts system for using electronic medical records to automatically submit case reports for notifiable diseases, and Evaluate the enhancement of electronic case reporting to provide longitudinal surveillance throughout the HIV continuum of care. Case identification using EHR data Development of longitudinal case reporting Current status and challenges Preliminary HIV care continuum data
ESP EHR Support for Public Health Software and architecture to extract, analyze, and transmit electronic health information from providers to public health Surveys codified EHR data for patients with conditions of public health interest Generates secure electronic reports for the state health department Designed to be compatible with any EHR system JAMIA 2009;16:18-24 MMWR 2008;57:372-375 Am J Pub Health 2012;102:S325 S332
ESP: Automated disease detection and reporting for public health Practice EMR s ESP Server Health Department diagnoses D P H lab results meds vital signs demographics Notifiable disease case reports JAMIA 2009;16:18-24 Am J Public Health 2012;102:S325 S332 Am J Public Health 2014;104:2265-2270
Case Identification ESP Chlamydia Acute Hepatitis B HIV
HIV Case Detection Algorithm Any of the following: Positive Western Blot Positive HIV Antigen/Antibody test and positive HIV ELISA HIV RNA Viral Load > 200 copies/ml HIV Qualitative PCR 2 ICD codes for HIV and history of prescription for 3 HIV meds ever HIV on problem list and history of prescription for 3 HIV meds ever Concurrent prescriptions for 2 sets of 3 or more different antiretrovirals at least 1 month apart PPV: 100.0% (95% CI: 98.5, 100.0); Sensitivity: 94.2% (90.5, 96.7).
Supplemental data provided with ESP case reports Patient demographics Age, Race/Ethnicity, Address, etc. Provider information Pregnancy status Symptoms Treatment information
ESP Notifiable Condition Case Reporting* Chlamydia Gonorrhea Acute Hepatitis A Acute Hepatitis B Acute Hepatitis C Chronic Hepatitis C HIV Influenza-like Illness Lyme Pertussis Syphilis Active Tuberculosis Latent Tuberculosis Infection *Diseases are in varying stages of implementation
ESP Notifiable Condition Case Reporting* Chlamydia Gonorrhea Acute Hepatitis A Acute Hepatitis B Acute Hepatitis C Chronic Hepatitis C HIV Influenza-like Illness Lyme Pertussis Syphilis Active Tuberculosis Latent Tuberculosis Infection *Diseases are in varying stages of implementation
Longitudinal Case Reporting Report initial case Including supplemental data from EHR Follow patients throughout the continuum of care Monitor disease progression Identify patients potentially out of care Monitor health outcomes
Prospective HIV Surveillance Serial lab results e.g., CD4 and HIV viral load test results Medical care visits New prescriptions Opportunistic infections Changes to pregnancy status Future expansion planned for screening, referrals, and care coordination
Challenges Identification of certain risk factors for HIV using EMR data Sexual orientation, transgender status, intravenous drug use, country of origin Validation/QC of new data elements reported from the EMR Housing status, HIV care visit Ongoing lab mapping maintenance Identification of indicators of in care status serial CD4 and HIV viral load test results, antiretroviral prescriptions, encounters associated with HIV or an opportunistic infection
Current Status for HIV Reporting Algorithm validation: Performed at 1 multi-site practice and 2 individual health centers In progress for 2 additional health centers Planned for 1 additional multi-site practice and several health centers In final stages of testing Expect longitudinal HIV case reporting to begin for at least 2 health centers this summer
Preliminary HIV Care Continuum Data ESP has capability to provide population-level aggregate summaries Included data from: 18 community health centers in Massachusetts Atrius Health, multisite ambulatory practice group Identified HIV patients in care in 2015 Evaluated proportion receiving HIV care
Preliminary HIV Care Continuum Data Care Continuum HIV patients in care in 2015 (N=3,362) Percent Follow-up encounter 97% Follow-up encounter with HIV diagnosis code Patients prescribed HIV medications Retained in care Patients with a viral load test Patients with a viral load test and prescribed HIV medications Virally suppressed Virally suppressed and on medications Opportunistic Infection 88% 87% 81% 71% 68% 63% 60% 3%
N = 19,071 N = 3,362 Percent of Individuals Comparison to Massachusetts Surveillance Data 100% 100% 100% 91% 80% 75% 81% 74% 60% 59% 65% 40% 20% 0% PLWHA Engaged in Care Retained in Care Virally Suppressed MDPH (2014) ESP (2015) http://www.mass.gov/eohhs/docs/dph/aids/mass-hiv-aids-plan.pdf
Continuity of Care in RiskScape
Coupling Surveillance and EHR Data Limitations of EHR data alone Not all data elements of interest are systematically captured in EHR Patients may get some of their HIV care (e.g., lab testing) outside of ESP partner practices Limitations of traditional surveillance data alone Burden on providers and MDPH to report and monitor cases With the exception of lab results, cannot easily capture care continuum data longitudinally
Acknowledgements Harvard Medical School/ Harvard Pilgrim Health Care Institute Micaela Coady Noelle Cocoros Michael Klompas JT Menchaca Aileen Ochoa Massachusetts Department of Public Health Gillian Haney Liisa Randall Hannah Rettler Sita Smith Atrius Health Benjamin Kruskal Commonwealth Informatics Karen Eberhardt Chaim Kirby Catherine Rocchio Bob Zambarano Massachusetts League of Community Health Centers Diana Erani Ellen Hafer Mark Josephson Cambridge Health Alliance James Griffith Brian Herrick Michelle Weiss
Extra Slides
Implementation Process Create HIV case detection algorithm Validate algorithm against medical charts and MAVEN Identify additional data elements and evaluate for accuracy and completeness Map data elements to standardized identifiers, such as LOINC and SNOMED codes Transmit data to MDPH s Health Information Reporting Portal via encrypted HL7 messages Integrate data into MAVEN upon initial detection and prospectively Enhance MAVEN to accept all EMR data elements of interest Create new data triage workflows
Preliminary Data New HIV Patients 100% Percent of Patients Newly Diagnosed with HIV in 2015 80% 60% 40% 20% 0% Linked to care Retained in care Virally suppressed 109 patients newly diagnosed with HIV
Preliminary Data New HIV Patients 100% Percent of Patients Newly Diagnosed with HIV in 2015 80% 60% 40% 20% 0% Linked to care Retained in care Virally suppressed Linked to care: Patients diagnosed with HIV in 2015 who had at least one viral load, CD4 test, or HIV prescription within 90 days of diagnosis
Preliminary Data New HIV Patients 100% Percent of Patients Newly Diagnosed with HIV in 2015 80% 60% 40% 20% 0% Linked to care Retained in care Virally suppressed Retained in care: New HIV patients who had at least one of the following in two different years following case date: viral load test, CD4+ test, encounter with an HIV diagnosis, or medications prescribed.
Preliminary Data New HIV Patients 100% Percent of Patients Newly Diagnosed with HIV in 2015 80% 60% 40% 20% 0% Linked to care Retained in care Virally suppressed Virally suppressed: New HIV patients whose most recent HIV viral load was less than 200 copies/ml.
Comparison to Ryan White HIV/AIDS Massachusetts State Profile Viral suppression is the percentage of people living with HIV whose last viral load result of <200 copies/ml among patient with: at least one outpatient visit during the calendar year at least one viral load reported Via ESP, 88.3% of HIV patients in care in 2015 achieved viral suppression. In 2014, 88.6% of Ryan White HIV/AIDS Program clients in Massachusetts achieved viral suppression (HRSA). https://hab.hrsa.gov/stateprofiles/client-clinical-characteristics.aspx
Comparison to Ryan White HIV/AIDS Massachusetts State Profile Retention in care is the percentage of PLWH who had at least one outpatient visit by September 1 of the calendar year, with a second visit at least 90 days after. Among patients with an outpatient visit before September 1 st Via ESP, 93.8% of HIV patients in care in 2015 were retained in care. In 2014, 86.1% of Ryan White HIV/AIDS Program clients in Massachusetts were retained in care (HRSA). https://hab.hrsa.gov/stateprofiles/client-clinical-characteristics.aspx